1. Pre-Op Athletic Participation 132 patients Recreational – 101 High School – 8 College – 21 Professional – 2 Recreational – 101 High School – 8 College – 21 Professional – 2

2. Operative Time – 63 minutes Number of sutures – 6 (3-9) Operative Time – 63 minutes Number of sutures – 6 (3-9)

3. Repeat Surgery for Instability 13 patients 8.6% 13 patients 8.6%

4. Subjective Symptoms 12 patients 8% 12 patients 8%

5. Bankart Scoring System Excellent 90 – 100 Good 75 – 89 Fair 51 – 74 Poor 0 – 50 Excellent 90 – 100 Good 75 – 89 Fair 51 – 74 Poor 0 – 50

6. Suture Technique Avg. Pre-op Bankart Score : 27 Avg. Post-op Bankart Score : 90 Avg. Pre-op Bankart Score : 27 Avg. Post-op Bankart Score : 90

7. Suture Technique Multiple attachments Superior and medical capsular advancement Avoid screw / staples about the shoulder Multiple attachments Superior and medical capsular advancement Avoid screw / staples about the shoulder

8. Previous Surgery Not a contradiction to arthroscopic reconstruction

9. Arthroscopic Reconstruction of the Shoulder

11. Suture Technique Suture Punch Five to Eight Sutures in Labrum Suture Punch Five to Eight Sutures in Labrum

15. Suture Technique Debridement

17. Suture Technique Abrade Anterior Glenoid Neck

19. Suture Technique Sutures placed through Beath Pin Sutures pulled posteriorly Sutures placed through Beath Pin Sutures pulled posteriorly

25. Arthroscopic Mulitsuture Repair for Anterior Instability 2 – 8 year follow up 150 Shoulders

26. Savoie – Caspari 1988 – 2 year follow up 50 shoulders 4% redislocation 4% resubluxation 1988 – 2 year follow up 50 shoulders 4% redislocation 4% resubluxation

27. Arthroscopic Bankart Results Torchia Caspari

28. M/M Follow Up 2 – 8.2 years Mean – 4.1 years Minimum – 2 years 2 – 8.2 years Mean – 4.1 years Minimum – 2 years

29. 150 Patients 3.6 year follow up

30. Chief Complaint Instability – 125 cases Overhead pain – 25 cases Instability – 125 cases Overhead pain – 25 cases

31. Etiology Trauma – 121 cases Repetative Microtrauma – 29 cases Trauma – 121 cases Repetative Microtrauma – 29 cases

32. Symptomatology Documented dislocation – 61 cases Duration of symptoms – 49 mos. (3 – 360) Documented dislocation – 61 cases Duration of symptoms – 49 mos. (3 – 360)

33. Symptomatology Sleep – 42 cases ADL’s – 85 cases Sports – 29 cases Sleep – 42 cases ADL’s – 85 cases Sports – 29 cases

34. Pre-op Surgical Procedures 34 Cases Open Stabilizations – 6 cases –Bankart – 1 –Bristow – 1 –Dutoit – 1 –Putti – Platts – 3 Open Stabilizations – 6 cases –Bankart – 1 –Bristow – 1 –Dutoit – 1 –Putti – Platts – 3

35. Pre-Op Surgical Procedures 34 Cases Arthroscopic Stabilizations – 4 Bankart – 1 Allografts – 2 Staple – 1 Arthroscopic Stabilizations – 4 Bankart – 1 Allografts – 2 Staple – 1

36. Pre-Op Surgical Procedures 34 Cases Other procedures –Arthroscopic Acromioplasties – 9 –Arthroscopic Labral Excisions – 8 –Diagnostic Arthroscopy – 1 –Arthroscopic Staple Removal – 1 Other procedures –Arthroscopic Acromioplasties – 9 –Arthroscopic Labral Excisions – 8 –Diagnostic Arthroscopy – 1 –Arthroscopic Staple Removal – 1

37. Pre-Op Surgical Procedures 34 Cases Other procedures – 24 cases –Open Acromioplasties – 2 –Suprascapular nerve decompression – 1 –Arthroscopic Synovectomy – 1 –Rotator Cuff Debridement – 1 Other procedures – 24 cases –Open Acromioplasties – 2 –Suprascapular nerve decompression – 1 –Arthroscopic Synovectomy – 1 –Rotator Cuff Debridement – 1

38. Photo of Athlete – swimmer gymnast or thrower.

39. Exam under anesthesia Dislocation – 86 75% Translocation – 45 50% Translocation – 5 Not Recorded – 14 Dislocation – 86 75% Translocation – 45 50% Translocation – 5 Not Recorded – 14

40. Photo doing exam in OR

41. Operative Findings Hill Sachs Lesions – 112 (51 superficial – 61 Deep) Bankart Lesions – 97 Capsular Laxity – 84 Hill Sachs Lesions – 112 (51 superficial – 61 Deep) Bankart Lesions – 97 Capsular Laxity – 84

42. Operative Findings Rotator Cuff tears – 20 (16 partial – 4 full thickness) Glenoid deficiency – 19 SLAP Lesions – 2 (Types I & III) Rotator Cuff tears – 20 (16 partial – 4 full thickness) Glenoid deficiency – 19 SLAP Lesions – 2 (Types I & III)

43. Photo of OR team doing shoulder surgery

44. M.E. Torchia, M.D. R.B. Caspari, M.D. M.A. Asselmeier, M.D. W. R. Beach, M.D. M. Garyari, M.S. M.E. Torchia, M.D. R.B. Caspari, M.D. M.A. Asselmeier, M.D. W. R. Beach, M.D. M. Garyari, M.S.

45. Arthroscopic Picture of Bankart Lesion

46. Reproduce slide by Maki***

47. Slide of ancients reducing a shoulder

48. M/M 1984 – 1992 156 Shoulders 150 Follow-up (96%) 1984 – 1992 156 Shoulders 150 Follow-up (96%)

49. M/M Chronic documented instability Single surgeon (RBC) Consecutive Procedures No Preselection Chronic documented instability Single surgeon (RBC) Consecutive Procedures No Preselection

50. Consecutive Procedures All patients with anterior instability were treated with arthroscopic repair

51. No Preselection Activity level Degree of laxity Prior surgery Pathological findings Activity level Degree of laxity Prior surgery Pathological findings

52. Chart Review Telephone Contact Recurrent dislocation Recurrent subluxation Bankart scores Revision surgery Recurrent dislocation Recurrent subluxation Bankart scores Revision surgery

53. M/M Follow-up Examination 31 Patients Physical Examination X-Rays Physical Examination X-Rays

54. Other Factors Operative time Number of sutures Duration of immobilization Post-op Complications Operative time Number of sutures Duration of immobilization Post-op Complications

55. Other Factors Pattern of Instability Degree of Instability Age Sex Extremity Dominance Pattern of Instability Degree of Instability Age Sex Extremity Dominance

56. Other Factors Athletic Activity Pre-op Physical Exam Previous Procedures Exam under anesthesia Athletic Activity Pre-op Physical Exam Previous Procedures Exam under anesthesia

57. Survival Analysis and Statistical Methods Kaplan – Meyer Method Predicts cumulative probability of failure as a function of time

58. Survival Analysis and Statistical Methods Peto – Peto Univariate analysis to setermine effect of patient and operative variables on probability of failure

59. Patient Characteristics 147 patients – 150 shoulders Mean Age – 29 years (14 – 67) 147 patients – 150 shoulders Mean Age – 29 years (14 – 67)

60. Patient Characteristics 104 men 43 women 97 dominant extremities 104 men 43 women 97 dominant extremities

61. Overview of Meniscal Lesions : Indications for repair John F. Meyers, M.D.

62. Introduction Meniscal injuries common Twisting mechanism Meniscal injuries common Twisting mechanism

63. Incidence Stable knees medial > lateral ACL Tears –Acutelateral > medial –Chronicmedial > lateral Stable knees medial > lateral ACL Tears –Acutelateral > medial –Chronicmedial > lateral

64. Treatment Options Excise Leave alone Repair Excise Leave alone Repair

65. Treatment History Total meniscectomy –Joint deterioration Partial Meniscectomy –Mixed results Total meniscectomy –Joint deterioration Partial Meniscectomy –Mixed results

66. Treatment History 1883 – Annadale 1936 – King 1948 – Fairbank 1969 – Ikeuchi 1970 – Dehaven 1980 – Henning 1883 – Annadale 1936 – King 1948 – Fairbank 1969 – Ikeuchi 1970 – Dehaven 1980 – Henning

67. Basic Science Anatomy –Fibrocartilagenous –Semilunar –Concave superior –Flat / concave inferior –Medial “C” shape –Lateral “O” shape Anatomy –Fibrocartilagenous –Semilunar –Concave superior –Flat / concave inferior –Medial “C” shape –Lateral “O” shape

69. Basic Science Vascular anatomy –Age dependent –Skeletal maturity –Peripheral penetration Medial 10 – 30% Lateral 10 – 25% Vascular anatomy –Age dependent –Skeletal maturity –Peripheral penetration Medial 10 – 30% Lateral 10 – 25%

71. Basic Science Histology –75% collagen –90% type I collagen –Fibers Circumferential Radial “ties” “hoops” Histology –75% collagen –90% type I collagen –Fibers Circumferential Radial “ties” “hoops”

73. Basic Science Function –Load bearing –Shock absorption –Joint stability –Joint lubrication Arnoczky et al, 1987 AAOS Function –Load bearing –Shock absorption –Joint stability –Joint lubrication Arnoczky et al, 1987 AAOS

75. Basic Science Healing sequence –Fibrin clot –Capillary budding –Fibrovascular scar –Fibrocartilage Healing sequence –Fibrin clot –Capillary budding –Fibrovascular scar –Fibrocartilage

77. Tear Classification Vascular Zone Position Pattern Vascular Zone Position Pattern

79. Vascular Zones Red-red Red-white White-white Red-red Red-white White-white

81. Indications No treatment –Partial thickness –<5mm length –<2mm displacement No treatment –Partial thickness –<5mm length –<2mm displacement

82. Indications Partial meniscectomy –Tear not amenable to repair Partial meniscectomy –Tear not amenable to repair

83. Indications Repair –Peripheral tear –Longitudinal tear –Young patient Repair –Peripheral tear –Longitudinal tear –Young patient

84. Indications Ideal repair situation –Traumatic tear –Acute injury –Vascular zone –Tear length > 7mm –Stable knee Ideal repair situation –Traumatic tear –Acute injury –Vascular zone –Tear length > 7mm –Stable knee

85. Contraindications Unstable knees > 5mm rim width Multiple longitudinal tears Non-surgical tears Unstable knees > 5mm rim width Multiple longitudinal tears Non-surgical tears

86. Special Tear Situations ACL Posterior horn LM Radial Avascular Zone ACL Posterior horn LM Radial Avascular Zone

91. Repair Techniques Open Outside – In Inside – Out All Inside Open Outside – In Inside – Out All Inside

93. Augmentation Techniques Fibrin clot Trephination Synovial abrasion Collagen scaffold Fibrin clot Trephination Synovial abrasion Collagen scaffold

95. Fibrin Clot Technique 50 – 70 cc venous blood Clot forms Clot tubularized or aspirated Cannula insertion or injected 50 – 70 cc venous blood Clot forms Clot tubularized or aspirated Cannula insertion or injected

99. Meniscal Repair Conclusion Alternative Treatment Restores Function Protective Effect Alternative Treatment Restores Function Protective Effect

102. Suture Technique Sutures tied over infraspinatus Fascia

103. Suture Technique Shoulder Immobilizer X 3 Weeks Out for Pendulum Exercises Daily Shoulder Immobilizer X 3 Weeks Out for Pendulum Exercises Daily

105. Post Repair Instability : Conventional Reconstruction Torg 8.5% : Modified Bristow Reconstruction Rowe 3.5% : Modified Bankart Reconstruction O’Driscoll 21% : Dutoit Staple Capsulorraphy Torg 8.5% : Modified Bristow Reconstruction Rowe 3.5% : Modified Bankart Reconstruction O’Driscoll 21% : Dutoit Staple Capsulorraphy

106. Post Repair Instability : Arthroscopic Reconstruction Johnson 15% : Staple Capsulorraphy Matthews 33% : Staple Capsulorraphy Johnson 15% : Staple Capsulorraphy Matthews 33% : Staple Capsulorraphy

107. 49 Suture Repairs

108. Re-Evaluation 2 – 6 Year post reconstruction Bankart Score Rowe : JBJS 1978 2 – 6 Year post reconstruction Bankart Score Rowe : JBJS 1978

109. Arthroscopic Bankart Repair 92% Satisfactory Results Decreased Morbidity Simple Technique, Avoid Staples or Screws Acceptable Method of Primary Reconstruction of the Unstable Shoulder 92% Satisfactory Results Decreased Morbidity Simple Technique, Avoid Staples or Screws Acceptable Method of Primary Reconstruction of the Unstable Shoulder

110. Post Repair Instability : Suture Repair Two Dislocations Two Subluxations Two Dislocations Two Subluxations

113. Open Surgicval Procedures for Anterior Shoulder Instability Repair of Capsule & Labrum Muscle and Capsule Plication Procedures Capsulorraphies Muscle & Tendon Sling Procedures Bone Block Procedures Osteotomies Repair of Capsule & Labrum Muscle and Capsule Plication Procedures Capsulorraphies Muscle & Tendon Sling Procedures Bone Block Procedures Osteotomies

115. Arthroscopic Procedures for Anterior Shoulder Instability Staple Capsulorraphy Rivet Capsulorraphy Cannulated Screw Fixation Allograft Reconstruction Bioabsorbable Tack Suture Repair Technique Staple Capsulorraphy Rivet Capsulorraphy Cannulated Screw Fixation Allograft Reconstruction Bioabsorbable Tack Suture Repair Technique

117. AIGHL must be sectioned to create anterior instability.

123. Shoulder Instability Classification & Differential Diagnosis Dislocation : “The complete displacement or disarrangement of the normal relation of the bones entering into the formation of a joint.”

124. Shoulder Instability Classification & Differential Diagnosis Subluxation : “An incomplete dislocation : though a relationship is altered contact between joint surfaces remains.”

125. Recurrent Anterior Instability Cofiekd : 82% < 20 years old Hovelius : 50% < 22 years old Cofiekd : 82% < 20 years old Hovelius : 50% < 22 years old

126. Recurrent Anterior Instability Rowe : 92% < 20 years old Henry : 90% recurrence rate Rowe : 92% < 20 years old Henry : 90% recurrence rate

127. Arthroscopic Findings in the Subluxating Shoulder F. J. McGlynn & R. B. Caspari C.O.R.R. 1984

128. Labral Detachment Hill-Sach Lesion Incompetent AIGHL Labral Detachment Hill-Sach Lesion Incompetent AIGHL